P105. Contrast Flow Volume Quantification for Therapeutic Transforaminal Epidural Injections

Proceedings of the NASS 22nd Annual Meeting / The Spine Journal 7 (2007) 1S–163S alignment restoration was satisfied in this group. The instrumentation levels were from T11 to L3 in 18 cases, T11~L2 in 6 cases, T11~L4 in 10 cases. In group B, the average curve correction was 73% with postoperative Cobb angle 15. METHODS: In group A, the patients received anterior mini-open approach without dissecting diaphragm. There were total 34 cases with average age of 16.2 years old, ranging from 12~25 years. The average Cobb angle was 58 ‘with a range of 42 ‘~76’ pre-operatively. In group B, the patients were treated with traditional open approach. Total 38 cases with average age of 16.8 years old, ranging from 13~26 years were included. The average Cobb angle was 54 ‘with a range of 40 ‘~74’ preoperatively. RESULTS: The instrumentation levels were from T10~L3 7 cases CT11~L3 20 cases CT11~L4 11 cases. The rehabilitation time was shorter in Group A than in Group B. No death, vascular injury and neurological complication occured. Exudative pleurisy occurred in two patients in each group and cured very well. CONCLUSIONS: Mini-open anterior instrumentation for thoracolumbar scoliosis without diaphragm dissection is proved to have the same outcomes as the traditional anterior approach, without the increase of complication. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2007.07.312

P105. Contrast Flow Volume Quantification for Therapeutic Transforaminal Epidural Injections Michael Furman, MD, MS1, Simon Jeremy2, Thomas Lee, MD3, Luke Rigolosi, MD4, Rikin Patel, DO5, Ryan Reeves6; 1Orthopaedic and Spine Specialists, York, PA, USA; 2Phys Med and Pain Mgmt Assoc, Bowie, MD, USA; 3Phys Med and Pain Mgmt Assoc, Columbia, MD, USA; 4 Northeast Orthopaedics, Albany, NY, USA; 5York, PA, USA; 6Ohio State University, Southlake, TX, USA BACKGROUND CONTEXT: L-TFESIs are an accepted treatment in the comprehensive, conservative care for low back pain with a radicular component secondary to lumbar disc pathology or spinal stenosis. The total volume(s) of injectate described in the literature varies from 1 cc to 5 cc. Recommendations exist regarding the appropriate total volume to be used to limit injectate spread to a single level. There is scant literature justifying the volumes typically used for L-TFESIs. PURPOSE: To quantify the volume of epidural contrast flow needed to reach specific therapeutic landmarks during fluoroscopically guided lumbar transforaminal epidural steroid injections (L-TFESIs). STUDY DESIGN/SETTING: Prospective, nonrandomized, observational human study. PATIENT SAMPLE: 41 patients with spinal stenosis and/or herniated nucleus pulposis undergoing L-TFESIs were investigated. OUTCOME MEASURES: Contrast injectate volumes were recorded as contrast was noted to bathe the 1) exiting spinal nerve, 2) superior intervertebral disc (IVD), and 3) inferior IVD. METHODS: 41 patients undergoing L-TFESIs were investigated. After confirming appropriate spinal needle position with biplanar fluoroscopic imaging, nonionic contrast was slowly injected until specific therapeutic landmarks were attained and contrast volumes documented. Specifically, injectate volumes were recorded as contrast bathed the 1) exiting spinal nerve, 2) superior intervertebral disc (IVD), and 3) inferior IVD. We compared data from patients with lumbar central spinal stenosis (LSS) and lumbar herniated nucleus pulposis (LHNP). RESULTS: Qualitatively, we confirmed that if contrast initially flowed extraforaminally, subsequent therapeutic flows would rarely approach either the superior or inferior IVDs consistantly. Once needle position was correctly placed, 0.2 ccþ/0.1 cc (meanþ/1 sd) was necessary to bathe the segmental nerve root, 1.2 ccþ/0.8 cc was necessary to bathe the superior IVD, and, 1.2 ccþ/0.8 cc was necessary to bathe the inferior IVD.

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2.6 cc of injectate bathed the superior IVD in 97.6% of our patients and 2.6 cc of injectate bathed the inferior IVD in 97.5% of our patient population. 3.0 cc of injectate bathed both the superior and inferior IVDs in 97.5% of our patient population. Volumes exceeding 0.3 cc are not uni-segmental in 87.5% of our injections and are, therefore, non-selective. Findings were similar in patients whose primary pathology was LSS and LHNP. CONCLUSIONS: Based on these findings, we recommend live contrast flow observation prior to therapeutic steroid injection and adjusting the needle tip position if flow is primarily extra-foraminal. A one level L-TFESI with 3.0cc volume will bathe both the superior and inferior IVDs 97.5% of the time. For therapeutic purposes, one may consider using this volume to maximize concentration and efficacy when the pathological segmental level is known. For diagnostic ‘‘block’’ procedures in the epidural space, L-TFESIs with more than 0.30cc are non-selective and cannot be used reliably to circumscribe a particular pain source. FDA DEVICE/DRUG STATUS: contrast: Approved for this indication. doi: 10.1016/j.spinee.2007.07.313

P106. Association of the Serum Folate Level and MTHFR, eNOS, TSER Polymorphisms and Vertebral Compression Fracture Risk in Korean Postmenopausal Women Young Sun Chung, MD1, Nam Keun Kim, PhD2, Ryoong Huh2, Sang Sup Chung2, Dong Eun Shin, MD3; 1Dept. of Neurosurgery, Bundang CHA Hospital, Pochon CHA University, Seongnam, Kyeonggi-do, South Korea; 2 Kyeonggi-do, South Korea; 3Dept. of Orthopedics, Bundang CHA Hospital, Pochon CHA University, Seongnam, Kyeonggi-do, South Korea BACKGROUND CONTEXT: 5,10-Methylenetetrahydrofolate reductase (MTHFR), a key enzyme in folate metabolism, plays a major role in the provision of methyl groups for DNA methylation; thymidylate synthase (TS) is a rate-limiting enzyme in the synthesis of dTMP and DNA repair; endothelium-derived nitric oxside(NO) is synthesized from l-arginine by endothelial nitric oxide synthase(eNOS) encoded by the eNOS gene on chromosome 7. MTHFR, TS, endothelial nitric oxide synthase (eNOS) are candidates in atherosclerosis-related diseases, such as cerebrovascular of cardiovascular diseases, as well as various cancers. However, the role of MTHFR, TS enhancer region (TSER) and eNOS polymorphisms for osteoporotic vertebral compression fracture in postmenopausal women susceptibility has not been reported. PURPOSE: To investigate serum folate level and MTHFR, eNOS and TSER genetic polymorphisms and its relation with the risk of osteoporotic vertebral compression fracture in Korean postmenopausal women. STUDY DESIGN/SETTING: Prospective case-control study. PATIENT SAMPLE: The study population was composed of 65 patients and 80 control subjects for 2 years. OUTCOME MEASURES: Assessment of the association of osteoporotic vertebral compression fracture in Korean postmenopausal women with the genotypes of MTHFR, TSER and eNOS. METHODS: Fasting serum homocysteine and folate levels were measured by fluorescence polarization immunoassay(FPIA) and competitive immunoassay, respectively. Genomic DNA was extracted from peripheral blood leukocytes. The nucleotide changes were determined by polymerase chain reaction (PCR)-restriction fragment length polymorphism analysis. RESULTS: The serum folate level was significantly low in vertebral compression fracture patients in Korean postmenopausal women, especially MTHFR 677CT, eNOS 894GG & GT and TSER 2R(-) genotypes. But, serum homocysteine level and eNOS G894T and MTHFR C677T polymorphisms were not statistically significant. CONCLUSIONS: This study suggest that low serum folate level and TSER 2R(-) genotype in Korean postmenopausal women may confer a higher risk of vertebral compression fracture. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2007.07.314